Imaging

Question 1

What are the two modalities most commonly used for scrotal imaging?

Answer 1

• Ultrasonography (US)
• Magnetic Resonance Imaging (MRI or MR)
  
  • Not used as often compared to ultrasound
  • May be used for more complicated cases

Question 2

What is the differential for painless scrotal swelling?

Answer 2

• Hydrocele, may be reactive
• Varicocele, usually left side, bag of worms
• Testicular mass – occasionally mild discomfort
  
  • Solid – usually malignant
    
    • Germ cell tumor, males 18 – 40 year old
    • Metastasis (leukemia, lymphoma, melanoma, GU tract)
  • Cyst – if simple, usually benign
• Extratesticular mass – usually benign
  
  • Cyst: Spermatocele or epididymal cyst
  • Solid: lipoma, adenomatoid tumor, inguinal hernia

Question 3

What is the differential for painful scrotal swelling?

Answer 3

• Epididymitis + orchitis, assoc UTI or prostatitis
• Torsion – sudden onset of pain
  
  • Post-pubertal and neonatal age group
  • Testis high riding, transverse orientation
  • Surgical emergency
• Trauma
  
  • Hematocele
  • Testicular hematoma and/or rupture
  • Surgical emergency if rupture
• Inguinal hernia – particularly if incarcerated

Question 4

What is a hydrocele and what are the findings on imaging?

Answer 4

• Accumulation of serous fluid within tunica vaginalis
• Small volume is normal
• Etiology: infection, trauma, tumor, idiopathic, rarely congenital
• Usually anechoic
• Occasionally contains low-level echoes and fibrin strands
• Unclear if treatment helps fertility, and treatment may injure epididymis

Question 5

What are the major findings of varicocele on imaging?

Answer 5

Large collection of vessels that show blood flowing away on imaging

Question 6

What are the findings of testicular torsion on imaging?

Answer 6

• Longitudinal US scan of the right hemiscrotum shows a round supratesticular mass, which represents an edematous spermatic cord
• There are several anechoic structures (arrowheads) within the mass, which probably represent obstructed and dilated lymphatic vessels.
• Bilateral transverse color Doppler images show no color flow signals in the right testis, which is enlarged and has heterogeneous echogenicity
• Reactive hydrocele and thickening of the scrotal wall are also seen

Question 7

What is the differential for hydronephrosis?

Answer 7

• Blockage >> Reflux
• Stone in renal pelvis or ureter
  
  • Most common cause of blockage in women and men
  • Often associated with flank pain and hematuria
• Enlarged prostate – BPH or cancer (older men)
  
  • Dilatation often bilateral
• Pregnancy (women)
  
  • Often unilateral on the right side
  • May have discomfort, rarely hematuria unless infection
• Blood clot in renal pelvis or ureter
  
  • Much less common than stone
  • Anticoagulation, coagulopathy, underlying process
• Urinary tract tumor (renal pelvis, ureter, bladder) or pelvic tumor blocking ureter
  
  • usually older patient
  • Typically painless hematuria
• Trauma – known history (blunt, penetrating, iatrogenic), hematuria, pain
• Neurogenic bladder – usually known history, dilatation often bilateral
• Ureter stricture/scarring due to prior stone, iatrogenic, trauma, congenital
• Congenital UPJ obstruction or megaureter – intermittent discomfort, rarely hematuria
• Persistent or recurrent urinary tract infection – signs and symptoms of infection